A nurse is assisting with the care of a client who was admitted to the telemetry unit after experiencing chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?
The PR intervals are 0.15 second.
The QT interval is equal to the R-R interval.
The QRS intervals are 0.08 second.
The ST segment is above the isoelectric line.
The Correct Answer is D
Choice A reason: The PR interval, which is the time from the onset of atrial depolarization (beginning of the P wave) to the onset of ventricular depolarization (beginning of the QRS complex), normally ranges from 0.12 to 0.20 seconds. A PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.
Choice B reason: The QT interval represents the total time for ventricular depolarization and repolarization. The normal QT interval varies based on heart rate and gender but is typically less than half of the R-R interval in a normal heart rhythm. Therefore, a QT interval equal to the R-R interval is abnormally prolonged, which may suggest other conditions but is not a specific indicator of acute myocardial infarction.
Choice C reason: The QRS complex reflects ventricular depolarization and normally ranges from 0.06 to 0.10 seconds. A QRS interval of 0.08 second is within the normal range and does not suggest an acute myocardial infarction.
Choice D reason: ST segment elevation is a critical finding in the diagnosis of acute myocardial infarction. The ST segment should be at the isoelectric line; elevation above this line is indicative of myocardial injury and is a key diagnostic criterion for ST-elevation myocardial infarction (STEMI). An elevated ST segment is often seen in the early stages of an acute myocardial infarction and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.
Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.
Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.
Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.
Correct Answer is C
Explanation
Choice A reason : Keeping the client in a high-Fowler's position for 6 hours post-cardiac catheterization is not recommended. After a femoral approach, it's important to keep the leg straight and the patient flat or with the head slightly elevated to prevent bleeding from the catheter insertion site. High-Fowler's position could increase the risk of bleeding and is not conducive to maintaining pressure at the arterial access site.
Choice B reason : Allowing the patient to ambulate around the room immediately after the procedure is contraindicated. The patient is typically required to remain on bed rest with the affected leg straight to prevent bleeding and ensure proper healing of the arterial puncture site. Ambulation is usually restricted for several hours post-procedure.
Choice C reason : Checking pedal pulses every 15 minutes is a critical action following cardiac catheterization via the femoral artery. It ensures that there is adequate blood flow to the extremity and helps to identify any complications such as occlusion or bleeding early. Adequate perfusion is indicated by strong and equal pedal pulses.
Choice D reason : Performing passive range-of-motion exercises for the affected extremity immediately after cardiac catheterization is not recommended. The affected leg should remain straight without bending at the hip to prevent bleeding from the catheter site. Passive range-of-motion could disrupt the vascular integrity at the puncture site and increase the risk of bleeding.
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